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The diagnostic accuracy of MRI in determining the relations between paraclinoid aneurysms and the cavernous sinus. Neuroradiology 2021; 64:1175-1185. [PMID: 34821948 PMCID: PMC9117373 DOI: 10.1007/s00234-021-02864-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
Purpose The location of paraclinoid aneurysms is determinant for evaluation of its intradural compartment and risk of SAH after rupture. Advanced MRI techniques have provided clear visualization of the distal dural ring (DDR) to determine whether an aneurysm is intracavernous, transitional or intradural for decision-making. We analyzed the diagnostic accuracy of MRI in predicting whether a paraclinoid aneurysm is intracavernous, transitional or intradural. Methods We conducted a prospective cohort between January 2014 and December 2018. Patients with paraclinoid aneurysms underwent 3D fast spin-echo MRI sequence before surgical treatment. The DDR was the landmark for MRI characterization of the aneurysms as follow: (i) Intradural; (ii) Transitional; and (iii) Intracavernous. The MRI sensitivity, specificity, positive and negative likelihood ratios were determined compared to the intraoperative findings. We also evaluated the intertechnique agreement using the Cohen’s kappa coefficient (κ) for dichotomous classifications (cavernous vs non-cavernous). Results Twenty patients were included in the cohort. The accuracy of MRI showed a sensitivity of 86.7% (95%CI:59.5–98.3) and specificity of 90.0% (95%CI:55.5–99.8). Analyzing only patients without history of SAH, accuracy test improved with a sensitivity of 92.3% (95%CI:63.9–99.8) and specificity reached 100% (95%CI: 63–100). Values of Cohen’s kappa (κ), intertechnique agreement was considered substantial for dichotomous classifications (κ = 0.754; p < 0.001). For patients without previous SAH, intertechnique agreement was even more coincident for the dichotomous classification (κ = 0.901; p < 0.001). Conclusion 3D fast spin-echo MRI sequence is a reliable and useful technique for determining the location of paraclinoid aneurysms in relation to the cavernous sinus, particularly for patients with no history of SAH.
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Liao CH, Lin CJ, Lin CF, Huang HY, Chen MH, Hsu SPC, Shih YH. Comparison of the effectiveness of using the optic strut and tuberculum sellae as radiological landmarks in diagnosing paraclinoid aneurysms with CT angiography. J Neurosurg 2016; 125:275-82. [DOI: 10.3171/2015.7.jns151046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE
The treatment of paraclinoid aneurysms remains challenging. It is important to determine the exact location of the paraclinoid aneurysm when considering treatment options. The authors herein evaluated the effectiveness of using the optic strut (OS) and tuberculum sellae (TS) as radiographic landmarks for distinguishing between intradural and extradural paraclinoid aneurysms on source images from CT angiography (CTA).
METHODS
Between January 2010 and September 2013, a total of 49 surgical patients with the preoperative diagnoses of paraclinoid aneurysm and 1 symptomatic cavernous-clinoid aneurysm were retrospectively identified. With the source images from CTA, the OS and the TS were used as landmarks to predict the location of the paraclinoid aneurysm and its relation to the distal dural ring (DDR). The operative findings were examined to confirm the definitive location of the paraclinoid aneurysm. Statistical analysis was performed to determine the diagnostic effectiveness of the landmarks.
RESULTS
Nineteen patients without preoperative CTA were excluded. The remaining 30 patients comprised the current study. The intraoperative findings confirmed 12 intradural, 12 transitional, and 6 extradural paraclinoid aneurysms, the diagnoses of which were significantly related to the type of aneurysm (p < 0.05) but not factors like sex, age, laterality of aneurysm, or relation of the aneurysm to the ophthalmic artery on digital subtraction angiography. To measure agreement with the correct diagnosis, the OS as a reference point was far superior to the TS (Cohen's kappa coefficients 0.462 and 0.138 for the OS and the TS, respectively). For paraclinoid aneurysms of the medial or posterior type, using the base of the OS as a reference point tended to overestimate intradural paraclinoid aneurysms. The receiver operating characteristic curve indicated that if the aneurysmal neck traverses the axial plane 2 mm above the base of the OS, the aneurysm is most likely to grow across the DDR and present as a transitional aneurysm (sensitivity 0.806; specificity 0.792).
CONCLUSIONS
High-resolution thin-cut CTA is a fast and crucial tool for diagnosing paraclinoid aneurysms. The OS serves as an effective landmark in CTA source images for distinguishing between intradural and extradural paraclinoid aneurysms. The DDR is supposed to be located 2 mm above the base of the OS in axial planes.
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Affiliation(s)
| | - Chung-Jung Lin
- 2Radiology and
- 3National Yang Ming University, School of Medicine, Taipei, Taiwan, Republic of China
| | - Chun-Fu Lin
- Departments of 1Neurosurgery, Neurological Institute, and
- 3National Yang Ming University, School of Medicine, Taipei, Taiwan, Republic of China
| | - Hsin-Yi Huang
- 4Biostatistics Task Force (under Department of Medical Research and Education), Taipei Veterans General Hospital; and
| | - Min-Hsiung Chen
- Departments of 1Neurosurgery, Neurological Institute, and
- 3National Yang Ming University, School of Medicine, Taipei, Taiwan, Republic of China
| | - Sanford P. C. Hsu
- Departments of 1Neurosurgery, Neurological Institute, and
- 3National Yang Ming University, School of Medicine, Taipei, Taiwan, Republic of China
| | - Yang-Hsin Shih
- Departments of 1Neurosurgery, Neurological Institute, and
- 3National Yang Ming University, School of Medicine, Taipei, Taiwan, Republic of China
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Brown B, Hanel RA. Endovascular Management of Cavernous and Paraclinoid Aneurysms. Neurosurg Clin N Am 2014; 25:415-24. [DOI: 10.1016/j.nec.2014.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Inoue S, Hosoda K, Fujita A, Ohno Y, Fujii M, Sugimura K, Kohmura E. Utility of 320-detector row CT for diagnosis and therapeutic strategy for paraclinoid and intracavernous aneurysms. Acta Neurochir (Wien) 2014; 156:505-14. [PMID: 24445734 DOI: 10.1007/s00701-014-1996-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 01/09/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was (1) to assess the diagnostic accuracy of 320-detector row computed tomography (CT) for paraclinoid and intracavernous aneurysms, and (2) to investigate whether this method provides sufficient information for surgery. METHODS A total of 14 patients with 16 unruptured proximal ICA aneurysms underwent three-dimensional CT angiography (3D-CTA) fusion imaging, which was created by superimposing 3D-CT venography data and/or 3D-bone data onto 3D-CTA data using 320-detector row CT, magnetic resonance imaging (MRI), and 3D digital subtraction angiography (DSA). The images of each modality were assessed using intraoperative findings as the reference standard. RESULTS All aneurysms were clearly visualized on 320-detector row CT. Bone subtraction and arterio-venous discrimination were accurate. On 3D-CTA fusion images, 11 aneurysms were diagnosed as "extracavernous" and five as "intracavernous". No discordance in aneurysm location between the 3D-CTA fusion images and the intraoperative findings was found. In contrast, discordance between MRI and intraoperative findings were found in five of the 16 cases (31%), which was significantly more frequent than with 3D-CTA (p = 0.043). The findings DSA, which was performed in nine patients, were also in excellent agreement with the intraoperative findings. However, 3D-CTA fusion imaging provided more comprehensive information, including venous and osseous structures, than 3D-DSA. The 320-detector row CTA after surgery demonstrated a clear relationship between the clip and aneurysmal neck with notably few artifacts, which suggested the utility of this modality for postoperative assessment. CONCLUSIONS The 320-detector row CT provided high accuracy for the diagnosis of paraclinoid and intracavernous aneurysms. This technique also provided comprehensive depiction of the aneurysms and surrounding structures. Therefore, this modality might be useful for the diagnosis of the paraclinoid and intracavernous aneurysms and for developing a surgical treatment plan.
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Lee SK, Kim JM. Internal carotid artery reconstruction using multiple fenestrated clips for complete occlusion of large paraclinoid aneurysms. J Korean Neurosurg Soc 2014; 54:477-83. [PMID: 24527189 PMCID: PMC3921274 DOI: 10.3340/jkns.2013.54.6.477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/16/2013] [Accepted: 12/12/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. Methods Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. Results Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. Conclusion The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.
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Affiliation(s)
- Sang Kook Lee
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Usefulness of the advanced neuroimaging protocol based on plain and gadolinium-enhanced constructive interference in steady state images for gamma knife radiosurgery and planning microsurgical procedures for skull base tumors. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 116:167-78. [PMID: 23417476 DOI: 10.1007/978-3-7091-1376-9_26] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKS) is currently performed with 0.1 mm preciseness, which can be designated microradiosurgery. It requires advanced methods for visualizing the target, which can be effectively attained by a neuroimaging protocol based on plain and gadolinium-enhanced constructive interference in steady state (CISS) images. METHODS Since 2003, the following thin-sliced images are routinely obtained before GKS of skull base lesions in our practice: axial CISS, gadolinium-enhanced axial CISS, gadolinium-enhanced axial modified time-of-flight (TOF), and axial computed tomography (CT). Fusion of "bone window" CT and magnetic resonance imaging (MRI), and detailed three-dimensional (3D) delineation of the anatomical structures are performed with the Leksell GammaPlan (Elekta Instruments AB). Recently, a similar technique has been also applied to evaluate neuroanatomy before open microsurgical procedures. RESULTS Plain CISS images permit clear visualization of the cranial nerves in the subarachnoid space. Gadolinium-enhanced CISS images make the tumor "lucid" but do not affect the signal intensity of the cranial nerves, so they can be clearly delineated in the vicinity to the lesion. Gadolinium-enhanced TOF images are useful for 3D evaluation of the interrelations between the neoplasm and adjacent vessels. Fusion of "bone window" CT and MRI scans permits simultaneous assessment of both soft tissue and bone structures and allows 3D estimation and correction of MRI distortion artifacts. CONCLUSION Detailed understanding of the neuroanatomy based on application of the advanced neuroimaging protocol permits performance of highly conformal and selective radiosurgical treatment. It also allows precise planning of the microsurgical procedures for skull base tumors.
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Yoon BH, Kim HK, Park MS, Kim SM, Chung SY, Lanzino G. Meningeal layers around anterior clinoid process as a delicate area in extradural anterior clinoidectomy : anatomical and clinical study. J Korean Neurosurg Soc 2012; 52:391-5. [PMID: 23133730 PMCID: PMC3488650 DOI: 10.3340/jkns.2012.52.4.391] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 08/14/2012] [Accepted: 10/04/2012] [Indexed: 12/27/2022] Open
Abstract
Objective Removal of the anterior clinoid process (ACP) is an essential process in the surgery of giant or complex aneurysms located near the proximal internal carotid artery or the distal basilar artery. An extradural clinoidectomy must be performed within the limits of the meningeal layers surrounding the ACP to prevent morbid complications. To identify the safest method of extradural exposure of the ACP, anatomical studies were done on cadaver heads. Methods Anatomical dissections for extradural exposure of the ACP were performed on both sides of seven cadavers. Before dividing the frontotemporal dural fold (FTDF), we measured its length from the superomedial apex attached to the periorbita to the posterolateral apex which connects to the anterosuperior end of the cavernous sinus. Results The average length of the FTDF on cadaver dissections was 7 mm on the right side and 7.14 mm on the left side. Cranial nerves were usually exposed when cutting FTDF more than 7 mm of the FTDF. Conclusion The most delicate area in an extradural anterior clinoidectomy is the junction of the FTDF and the anterior triangular apex of the cavernous sinus. The FTDF must be cut from the anterior side of the triangle at the periorbital side rather than from the dural side. The length of the FTDF incision must not exceed 7 mm to avoid cranial nerve injury.
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Affiliation(s)
- Byul Hee Yoon
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
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Javalkar V, Banerjee AD, Nanda A. Paraclinoid carotid aneurysms. J Clin Neurosci 2011; 18:13-22. [PMID: 21126877 DOI: 10.1016/j.jocn.2010.06.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 06/15/2010] [Accepted: 06/20/2010] [Indexed: 02/07/2023]
Affiliation(s)
- Vijayakumar Javalkar
- Department of Neurosurgery, Louisiana State University Health Sciences Center - Shreveport, 1501 Kings Highway, Shreveport, Louisiana 71103, USA
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Lee D, Kim TH, Kim BS, Ihn YK, Won YD, Chung J, Shin YS, Lee KS. Imaging of Distal Dural Ring Plane and Paraclinoid Internal Carotid Artery Aneurysms with 3D Rotational Angiography. Neurointervention 2010. [DOI: 10.5469/neuroint.2010.5.2.85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Dongwoo Lee
- Department of Neurosurgery, Cheju Halla Hospital, Jejudo, Korea
| | - Tae-Hyung Kim
- Department of Radiology, The Catholic University of Korea, Korea
| | - Bum-Soo Kim
- Department of Radiology, The Catholic University of Korea, Korea
| | - Yeon-Kwon Ihn
- Department of Radiology, The Catholic University of Korea, Korea
| | - Yoo Dong Won
- Department of Radiology, The Catholic University of Korea, Korea
| | - Joonho Chung
- Department of Neurosurgery, Inha University School of Medicine, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, The Catholic University of Korea, Korea
| | - Kwan Sung Lee
- Department of Neurosurgery, The Catholic University of Korea, Korea
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Figueiredo EG, Tavares WM, Rhoton AL, De Oliveira E. Surgical nuances of giant paraclinoid aneurysms. Neurosurg Rev 2009; 33:27-36. [PMID: 19760439 DOI: 10.1007/s10143-009-0224-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 05/20/2009] [Accepted: 07/05/2009] [Indexed: 12/14/2022]
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Tsuboi T, Tokunaga K, Shingo T, Itoh T, Mandai S, Kinugasa K, Date I. Differentiation between intradural and extradural locations of juxta-dural ring aneurysms by using contrast-enhanced 3-dimensional time-of-flight magnetic resonance angiography. ACTA ACUST UNITED AC 2007; 67:381-7. [PMID: 17350409 DOI: 10.1016/j.surneu.2006.08.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Accepted: 08/04/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Juxta-dural ring aneurysms of the ICA have different clinical outcomes and risks for SAH, which are dependent on their position in the intradural or extradural space. The aim of this study was to reveal the precise location of such aneurysms by using CE-MRA. METHODS Contrast-enhanced MRA studies were performed in 21 patients with 24 juxta-dural ring aneurysms. The locations were evaluated by source images of CE-MRA and MPR images. We evaluated the accuracy of preoperative MRI findings by comparing imaging results with intraoperative findings in 7 cases. RESULTS The CS was clearly enhanced in the CE-MRA technique, which allowed the precise identification of these aneurysms as intradural or extradural. Intracavernous aneurysms were diagnosed when the greater hyperintensity of the aneurysm was located within the less hyperintense region of the contrast-enhanced CS. Nine of the cases were diagnosed as intradural aneurysms, and 15 aneurysms were noted as extradural based on the findings of CE-MRA. Surgery was performed in 7 cases, which included 4 intradural and 3 extradural aneurysms, and the preoperative MRI findings corresponded with the intraoperative findings in all cases. CONCLUSION Contrast-enhanced MRA and MPR are very useful techniques for determining the location of juxta-dural ring aneurysms.
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Affiliation(s)
- Toshiyuki Tsuboi
- Department of Neurosurgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan.
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Andaluz N, Tomsick TA, Keller JT, Zuccarello M. Subdural hemorrhage in the posterior fossa caused by a ruptured cavernous carotid artery aneurysm after a balloon occlusion test. J Neurosurg 2006; 105:315-9. [PMID: 17219840 DOI: 10.3171/jns.2006.105.2.315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓Given the relatively benign natural history of cavernous carotid artery aneurysms and based on anecdotal reports in the literature of subarachnoid hemorrhage (SAH) or subdural hemorrhage (SDH) from these aneurysms, observation is warranted and typically recommended. In this case report, the authors describe a woman who harbored a partially thrombosed, giant cavernous aneurysm that ruptured after she underwent a balloon occlusion test (BOT) and predominately led to an SDH. The authors believe that this occurrence is the first such report in the English literature. They discuss possible mechanisms for this event and the literature related to SAH or SDH from cavernous aneurysms, including why cavernous aneurysms cause such hemorrhages. The authors also recommend that attention be paid to such lesions regarding the possibility of aneurysmal rupture following a BOT.
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MESH Headings
- Adult
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/diagnosis
- Aneurysm, Ruptured/therapy
- Balloon Occlusion/adverse effects
- Carotid Artery Diseases/complications
- Carotid Artery Diseases/diagnosis
- Carotid Artery Diseases/therapy
- Carotid Artery, Internal/pathology
- Cavernous Sinus/pathology
- Cerebral Angiography
- Cerebral Infarction/diagnosis
- Dominance, Cerebral/physiology
- Embolization, Therapeutic
- Female
- Hematoma, Subdural/diagnosis
- Hematoma, Subdural/etiology
- Hematoma, Subdural/therapy
- Humans
- Ophthalmoplegia/etiology
- Parietal Lobe/pathology
- Postoperative Complications/diagnosis
- Postoperative Complications/etiology
- Postoperative Complications/therapy
- Tomography, Emission-Computed, Single-Photon
- Tomography, X-Ray Computed
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Affiliation(s)
- Norberto Andaluz
- The Neuroscience Institute, Department of Neurosurgery, University of Cincinnati College of Medicine, Ohio 45267-0515, USA
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Thines L, Delmaire C, Le Gars D, Pruvo JP, Lejeune JP, Lehmann P, Francke JP. Localisation en IRM des anévrismes carotidiens paraclinoïdiens. J Neuroradiol 2006; 33:115-20. [PMID: 16733425 DOI: 10.1016/s0150-9861(06)77240-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM The distal dural ring plane (DDRP) separates the intracavernous from the supracavernous paraclinoid internal carotid artery. The purpose of this MRI protocol is to evaluate the position of this plane for the characterization of paraclinoid aneurysms. METHOD The protocol uses a T2 weighted sequence in two orthogonal planes (diaphragmatic and carotid planes) and two correlation lines in each plane. These lines pass through anatomo-radiological reference points correlated with the medio-lateral and antero-posterior margins of the DDRP. We use the intersection angle of these lines as the inferior radiological limit of the DDRP curve. RESULTS An aneurysm located above this angle is supracavernous; an aneurysm located below this angle is intracavernous; an aneurysm crossing this angle is transitional. CONCLUSION In difficult cases, this MRI protocol could help better characterize the exact localization of paraclinoid aneurysms on both sides of the cavernous sinus roof.
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Affiliation(s)
- L Thines
- Clinique Neurochirurgicale, Hôpital Roger-Salengro, CHRU, rue du Professeur Emile Laine, 59037 Lille Cedex.
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